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Symptom: Pain, Muscle

Initial Grading Reminder

Grade 1: Mild pain
Grade 2: Moderate pain; limiting instrumental ADLs
Grade 3: Severe pain; limiting self-care ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you done any activity recently that could have contributed to the muscle pain? When did the symptom start? Has it developed gradually or suddenly? Have you had any muscle pain in the past?

Grade the symptom

Ask the patient:

How would you rate your muscle pain: is it mild, moderate, or severe? Is it limiting your ability to do the things you want to do or take care of yourself?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you feeling foggy or confused? Have you been vomiting? Is your urine tea-colored?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with new-onset moderate or worse (or worsening) muscle pain should be evaluated.

    Patients with any of the red-flag symptoms should be evaluated immediately.

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    Nursing Assessment of Potential Causes

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    Rhabdomyolysis

    Pain, muscle weakeness, vomiting, confusion, tea-colored urine, laboratory markers (elevated creatine kinase levels)

    Differential Diagnosis

    What do you suspect is the cause of the muscle pain?

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